Methadone Maintenance and Intra-Agency Processes of Care: Hospital Admissions for a Traumatic Medical Event and Interruptions in Treatment

Background and Purpose: A strong association between substance use and traumatic injuries has been well established in the literature. Further, a high prevalence of substance use disorders has been noted among trauma center patients. The Pennsylvania Trauma Systems Foundation, the accrediting body for state trauma centers, requires a social work evaluation for every admitted trauma patient suspected of substance abuse and the provision of an intervention for patients identified as at risk for substance abuse. However multiple barriers inhibit the facilitation of interventions for patients with substance use disorders already enrolled in methadone maintenance treatment (MMT). Methadone use increases opiate tolerance and complicates achieving pain control following traumatic injuries. Methadone maintenance programs often deny reentry for patients using other substances, including prescribed opiates. Inpatient physical rehab facilities, both skilled and acute-level care, deny admission for patients on MMT as they lack the necessary physician oversight and/or coordination with community-based treatment programs to provide methadone. Thus, physical rehabilitation during the acute hospital admission and discharge to the community is frequently the only option for patients. Interruptions in MMT as a result of a medical hospital admission represent a significant obstacle to timely discharge and reentry into community-based treatment programs. Early identification of methadone maintenance is critical to effective pain control, appropriate discharge planning and decreasing length of stay (LOS).

Methods: This retrospective cohort study examined the medical records of all adult patients admitted to the trauma service of the Hospital of the University of Pennsylvania July 1, 2008 to November 1, 2008 with a social work identified need of MMT. Electronic medical records (EMR) including social work case notes, pharmacy records, and physician documentation were compared for temporal congruence in: identification of substance abuse history, verification of MMT and dose by the community-based agency, and date of inpatient methadone administration. The relationship between early identification and verification of MMT and length of stay was examined. Finally, we assessed the need for a verification and treatment protocol for trauma patients with suspected MMT.

Results: Of the 586 patients admitted during the study period, only 6 patients had clear documentation of MMT in the social work case notes. No cases had verification of community-based treatment and dose upon admission, and there was no clear pattern of when confirmation was made during the course of the hospital stay. There was no EMR documentation by either physicians or nurse practitioners of dose verification prior to administration of methadone in the hospital. No temporal consistency between verification of methadone dose and when methadone was first administered was found. Reentry into treatment was complicated for half of the cases, however no clear relationship between dose verification, dose administration and LOS was established.

Conclusions and Implications: The lack of documentation and clear processes of care for these patients highlights the need for a protocol for to identify MMT upon admission, verification of dose, and restart administration of dose. A quality initiative protocol to facilitate continuity of care for trauma patients on methadone maintenance was developed.